A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?

1 cm below the umbilicus

3 cm below the umbilicus

2 cm above the umbilicus

3 cm above the umbilicus

Answer and Explanation

The Correct Answer is C

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

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Correct Answer is D

Explanation

Choice A: While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.

Choice B: While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.

Choice C: TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.

Choice D: Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.

A. The largest fetal diameter has passed through the pelvic outlet. B. The lowermost portion of the presenting part is at the level of the ischial spines. C. The posterior fontanel is palpable. D. The fetal head is in the left occiput posterior position.

Correct Answer is B

Explanation

A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect

interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.

B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?